List of Professional Practice Briefs

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1 List of Professional Practice Briefs Checklist for HIM Readiness This PPB identifies 28 components to be considered in the transition of the paper based to EHR HIM Department from getting started to forms, interfaces and comprehensive departmental plans. In addition, it provides references to additional reference material. Delving Into Computer Assisted Coding This PPB discusses computerized coding tools, identifying the influence of the technologies, and provides guidance on how coding professionals of today can position themselves for the coming coding revolution. Health Data Access, Use, and Control for Secondary Uses There is a perception that it is permissible to access and use data for secondary purposes if an individual/organization owns the media. Linking, sharing, and retrieving information has been made easier by technology in that it can be transmitted, shared, and leveraged for a myriad of purposes to multiple users more quickly. This PPB discusses secondary use of health data considering key factors including: the status of the data in the context of a legal record; the de identification of data; contracts and business arrangements, provincial/federal laws; and the right of the individual about whom the data is collected. Visioning ehim: A Process for Imagining &Anticipating HIM's Future The transformation from paper based to EHR will impact every aspect of health information management. Every fundamental will need to be rethought and affirmed or discarded. To face this future, HIM professionals must envision the future and develop a mapping strategy; this PPB provides key steps and resources for this process. Data Standards, Quality and Interoperability The PPB identifies a list of standards to reference in data dictionary development, evaluation of health data software applications, EHR tools, and general management processes to ensure information integrity and reliability. EHR Career Opportunities The migration of health care organizations to the EHR will affect the entire HIM profession. Many new and altered job titles and roles are emerging. This brief identifies a few of these new career opportunities. Speech Recognition This PPB is intended to increase the HIM professional s understanding of how the technology works the driving forces for this technology, and the benefits and risks. It provides a glossary of terms and illustrates the work flow, tasks and best practices for this new technology and process. Electronic Document Management as a Component of the EHR With the evolution of the EHR, organizations are becoming cognizant of EDMS to manage both paper and electronic computer generated documents. This PPB is a compilation of best practices detailing the keys steps and issues in implementing an EDMS.

2 Essential People Skills for EHR Implementation Success Successful EHR implementations require people skills everything from leadership, communication and training to change management. This PPB outlines some of success factors for EHR adoption and the people skills for HIM professionals. Tools that can assist in assessing readiness of change are identified. Facsimile Transmission of Health Information This PPB discusses the technology and legal requirements associated with FAX transmission. It identifies 10 recommendations for safely using this communication technology, and a few steps in dealing with a breach. The RHIO Landscape Health care organizations have many approaches to the sharing of health care data. This PPB describes several types of linkages and the three levels of complexity in the practical application of EHR technologies. Identity Theft The Impact on HIM Operations Identity theft is the crime of the 21st century, and health care organizations are particularly vulnerable due to the wealth of information collected, stored, maintained, and transmitted. This PPB identifies practical preventive guidance; how to resolve ID theft in an MPI; and discusses how to respond to an ID theft within your organization. Wireless Communication: Safeguarding Privacy and Security This PPB discusses select new communication technologies (such as Bluetooth) and the challenges associated with these. Specific advice is given in how to deal with these technologies as they become mainstream in health care delivery. Guidelines Developing a Data Dictionary Information systems are only as good as their data. Without agreed clearly defined terms and definitions, validity and reliability of data are suspect. The data dictionary is a building block of effective health information systems supporting health care delivery. This PPB defines a data dictionary, explains their purpose, and provides specific guidelines to create and maintain this pivotal EHR component. Data for Electronic Patient Record (EPR) Documentation Structured data enhance the flow of information into an EPR and ultimately into the pan Canadian EHR. HIM professionals must understand the data standards and how these standards support effective information management. This PPB discusses data dictionaries, data standards, and data content to support an EPR. Privacy and Security in a Health Information Exchange (HIE) With the development of local, regional, and provincial networks for the exchange of health data, it is important that HIM professionals are aware of the many related privacy and security issues. This PPB provides a brief description of the types of HIE environments, and discusses some of the considerations within legal and operational issues. These include: variations in laws; data sharing agreements; accountability for privacy; consent; ensuring safeguards; and identity management.

3 Disaster Planning for Health Information Services Most HIM departments never experience a disaster; however a well designed action plan will protect health information (regardless of format) from damage and minimize disruption. This PPB provides guidance in creating a disaster plan specific to health information. Assessing and Improving EHR Data Quality Quality health care depends on the availability of quality data. Without accurate and appropriate content in a usable and accessible form, the incredible value of the EHR will not be realized. This PPB identifies 5 best practices, and the potential technical challenges for data quality. Guidelines for EHR Documentation to Prevent Fraud This brief offers guidelines to prevent potential EHR documentation fraud including guidelines for electronic documentation, a check list and three case studies. Writing a Business Case At some point in their career, it is likely that an HIM professional will need to provide a compelling solid rationale to a Senior Manager. This PPB will outline the key steps in creating an effective Business Case and provides a checklist for reference. Building an EMPI Clinical care relies on the basic premise that an organization can accurately identify clients. An enterprise master patient/person index (EMPI) is a software application that identifies persons in an integrated delivery network across disparate registration, scheduling, financial, and clinical systems. Limiting Disclosure the "Lock Box" A fundamental principle of CSA Model Code for the Protection of Personal Information is that of Informed Consent. The corollary of this is that the person has the right to withhold or withdraw consent to disclosure. This PPB discusses the challenges, limitation and legislation of limiting disclosure, and articulates suggestions for addressing a person s request to lock their data. as a Provider Patient Communication can be effective in facilitating communication between health care providers and patients. It offers many benefits, but requires safeguards different than other communication such as paper and phones. This PPB outlines some of the challenges and benefits of , as well as identifies recommendations for the HIM professional in dealing with this communication medium. Health Information Management (HIM) & Health Information Technology (IT) This PPB discusses the connection and working relationship between Health Information Management and Health Information Technology in the developing EHR. These two different but related disciplines are essential to the successful development and deployment of the EHR in Canada. An understanding of the three domains that require collaboration will assist an HIM professional to become a valuable member of an EHR team and bring needed skill sets to an organization. Personal Health Record in the EHR A new component of the Electronic Health Record is the Personal Health Record (PHR). Created, owned, maintained and shared by the individual, the PHR will impact the existing health care records regardless of setting, and therefore will impact the HIM professional. The advent of the PHR will require the HIM

4 professional to rethink organizational approaches to health information collection, dissemination and access and to adapt to ever changing new technologies. An IT Primer for Interoperable Health Information With a demonstrated understanding of basic internet and IT terminology related to data exchange, HIM professionals can improve communication between technical and clinical professionals. Serving as a bridge between the professions, HIM professionals can facilitate the successful adoption and use of exchanged clinical information. Health Level 7 Standards are the most effective and efficient way to facilitate interoperable systems. If Canada s health service delivery organizations implemented the same standards in their information management systems, data and information exchange would be facilitated. With the transition to the Electronic Health Record, HL7 is one standard with which HIM professionals should be familiar. This PPB describes HL7 at a high level and identifies references and resources available to all HIMs. Standards Councils A pan Canadian Electronic Health Record requires standards technical, data, process, information, etc. These standards must be developed, implemented, monitored, and changed as appropriate and these activities must be coordinated. One key piece of the implementation of standards is the Health Standards Council. This Professional Practice Brief is a primer on what a Standards Council is, how it operates, and identifies common activities and goal of Councils across Canada. Principles of the Electronic Health Record (EHR) Within the healthcare industry there is a growing need and increasing urgency for the establishment of sound guiding principles to support evolving electronic health records (EHR). This paper explores many of these principles within the health care industry. The HIM Profession in Telemedicine Telemedicine is a method of enabling the delivery of health care to patients/clients at a distance, using different telecommunication and information technologies eliminating barriers such as distance, patient mobility, and challenges related to health professional or specialist access and availability. As Health Information Management (HIM) professional opportunities expand beyond traditional hospital and clinical care settings, the area of Telemedicine is worth exploring. This PPB provides an overview of opportunities for the HIM in telemedicine. The HIM Role in Patient Safety and Quality of Care The focus on patient safety and quality care has resulted in many initiatives in agencies, the regulatory environment, the information and communication domains, education, research and professional ethics. All of these are influenced by changing evaluation methodologies, new technology and system innovation issues. The role of the HIM professional within patient safety spans the scope and breadth of ehealth transformation, standards setting, system functions, information and screen design, MPI, documentation practices, technology, performance management, patient advocacy, ethics, workflow, data quality, and data reporting. This PPB provides an overview of the many agencies and influences that have increased the profile of Patient Safety and Quality Care in Canada and the important role of the HIM professional.

5 Research: A Brief Overview What is research? This PPB is intended to highlight what research is and how HIM professionals can be involved. The document discusses the types of research, associated paradigms, and tools as well as the basic steps to the research process The Role of the HIM Professional in Primary Care An exciting and expanding opportunity for the Health Information Management (HIM) professional lies within the primary care setting. As technology advances with the move to the electronic health record (EHR), it is evident that HIM expertise is needed at the primary source of health information. This practice brief delivers an overview of HIM in the primary care setting and within Family Health Teams including areas for HIM involvement and reasons why HIM professionals should be a part of the Family Health Team model. This brief also touches on the composition of the primary care record and record management practices. As primary care evolves from the paper based record to the electronic medical record (EMR), it is important to note the documentation requirements for all care providers as well as access, storage, backup, recovery/retention, and destruction in the electronic environment. This PPB provides an overview of opportunities for the HIM professional in primary care

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